One curious feature of our current moment in health policy is how divergent the impending course of action pledged by Republicans in Congress and the incoming Trump administration is from the preferences of major health care industry stakeholders. Dominant models of public policy making assume that the preferences of large economic stakeholders in a given policy area will exert a lot of sway over the outcome. To be sure, every interest group has something(s) they want to change about the Affordable Care Act (ACA), but there is very little appetite among providers, hospitals or insurers for rolling back coverage. For example, a recent survey in Modern Healthcare found overwhelming opposition from health care CEOs to repealing in the ACA without a replacement at the ready. Yet that is the course the Congressional Republicans seem ready to embark on – inflicting serious pain in the process, especially on providers (not to mention the millions of Americans who stand to lose coverage).
It seems hard to imagine a parallel in any other industry. (Of course, the banking industry didn't exactly love the Dodd-Frank bill, but its passage was only made possible by the self-inflicted meltdown of the industry). The present situation is so unusual that it demands an explanation. I don't presume to be able to peer into the minds of the repealers, but I think there is some combination of three things going on:
- Ideological extremism. An anti-government ideology is so profoundly held within most of the Republican leadership in Congress today that pursuing fervently desired goals is totally unmoored from considering any real-world consequences. Thus, the ACA must be repealed “because-government.” The real-world harms – the rise in medical debt and personal bankruptcy, the erosion of hospital finances, the increases in mortality – are just not germane.
- Health care as "piggybank." The money for touted big tax cuts for the wealthy and increased military spending has to come from somewhere. With federal discretionary spending already pared to the bone, there just isn't another major source of money beside the health realm to tap in order to pay for these "more important" priorities.
- “The dog catches the car” problem. For years, Congressional Republicans have been able to score political points railing against the ACA and passing veto-certain repeal measures without having to deal with the pesky problem of figuring out what would come after. The election of Donald Trump caught pretty much everyone by surprise, but it is far too late now to moderate the rhetoric. Repeal has been repeatedly promised and now, with control of both houses and the presidency, come January, the promise must be fulfilled regardless of the problems it might cause. There is no room for backtracking.
Are Republicans Serious About "Replace"? We'll Find Out Soon
To be fair, there are some real ideas out there on the Republican side about how to replace some provisions of the ACA. For example, various policy makers and conservative academics have proposed a variety of alternatives to the individual responsibility requirement, including continuous coverage, auto-enrollment and late enrollment penalty. Different ways to design financial assistance and minimum coverage are also possible (not to say that these alternatives would work better than the ACA). The problem is how these ideas interact with the "piggybank" scenario (see #2, above). Any serious alternative requires money. If the first thing the new Congressional leadership and incoming president do is pull a ton of money out of the system, it will be an early sign they are not serious about health policy and that repeal is just a stalking horse for transferring wealth up the income scale.
Now Is the Time to Speak Up!
It cannot be overemphasized that the threat to create chaos in health care for millions of Americans extends far beyond proposals to roll back the coverage gains made by the ACA. Enormous cuts to Medicaid are also on the table. Even Medicare is not safe, a fact underscored by the recent comments of Representative Tom Price, thought to be a leading contender for the top job at Health and Human Services under a Trump administration, who confirmed that the efforts to overhaul (aka cut) Medicare would begin in 2017. It is fair to say that there is no electoral mandate for these cuts to Medicaid and Medicare, but the American people may very soon find these programs at risk, nonetheless.
The takeaway is that while the ACA may be first on the chopping block, Medicaid and Medicare will follow closely behind unless we mobilize now to save these vital programs. Members of Congress are saying they aren't hearing from people complaining about repeal, so it’s crucial for all of us to raise our voices loudly right now.